Client Information

Client Information
Date: *

Month Day Year
Date
Client Name: *
Date of Birth: *

Month Day Year
Date
Age: *
Sex (biological): *
Gender (how you identify): *
Ethnicity: *
Home Address: *
Home Phone Number: *
Mobile Number: *
May we leave a message? *
Email address: *
example@example.com
Referral Source
Who may we thank for your referral to our office, or how did your learn about our practice? *
Emergency Contact Information
In case of an emergency, who should we contact? *
Relationship: *
Phone Number: *
Client History
Who is providing the history information here? *
Please provide any details regarding what brought you to counseling: *
Previous Treatment
Have you received or participated in previous counseling and/or therapy? *
Was the treatment you received helpful? *
Have you had hospital stays for psychological concerns? *
Additional Information:
Medical History

List any current or important past medications:
Medication & Dose: *
Response to Medication: *
Any current health concerns, serious illnesses, or conditions: *
Indicate any allergies you have: *
How would you rate your current physical health? *
What was the approx date of your last physical or routine health “check up? *

Month Day Year
Date
Marital History
Which best describes your marital status? *
Do you have children (please include stepchildren or any children for whom you are responsible)? *
If yes, please give first name, gender, and age for each one:
Do you have custody of your children? *
Are there presently any child custody issues involving you or your family? *
Does your family currently have Child Protective Services Involvement? *
Legal History
Do you currently have any pending criminal? *
Are you on probation? *
Have you ever been arrested/convicted of a crime other than traffic misdemeanors? *
If you answered yes to any of these three questions, please explain:
Safety
Have you recently (within the last two weeks) experienced any thoughts of harming either yourself or someone else? *
Have you in the past experienced thoughts of harming either yourself or someone else? *
Have you ever attempted to kill yourself? *
Have you ever physically attacked or been in a physical altercation with someone else? *
If you answered yes to any of the above please explain in as much detail as possible:
Fee Agreement
Name *

First Name Last Name
Date *

Month Day Year
Date
Insurance Provider *
Insurer ID: *
*No copay or out of pocket costs for clients with Medicaid plans.
Self Pay Rates:

Individual Session: $85.00

Couples/Family Session: $100

Psychological Testing: $400
**Missed Appointment/Late Cancellation: Equal to your session fee
Name on Card: *
Credit Card Number: *
Expiration Date: *
CVV: *
Zip Code: *
I, (client or parent/guardian), authorize Poppy’s Therapeutic Corner to charge my credit card via the Square App or Ivy Pay App after each session.

I authorize Poppy’s Therapeutic Corner, LLC to charge my credit card in the case of an emergency (imminent risk of harm to self or others).

If services are school, office, or telebased, I understand that I will not be present every time my card is billed. I understand that I need to notify my therapist in writing to discontinue services and for my credit card to stop being charged for services. I understand that my information will be saved to file for future transactions on my account.
Client Responsibilities and Fee Information
- Each person is expected to pay his/her fee at the time of service.
- Notify your therapist if there are any changes to your insurance benefits or if your insurance is discontinued.
- No shows or cancellations without a 24 hour notice will be charged the self-pay cost of the session, which is not reimbursable by insurance. No show fees do not apply to school-based clients.
- All inquiries into pre-certification, benefits, treatment plans (if necessary), coverage, etc. are the client’s responsibility.
- Payment is expected at the time of service and the client has the ultimate responsibility for their account and making sure insurance payment is received if using insurance.
- If a claim is denied it is the client’s responsibility to pay their account upon notification of denial at the insurance reimbursement rate. If payment is not received for services rendered in a timely manner I understand that Poppy’s Therapeutic Corner, LLC will release my information to a third party Credit agency to attempt to collect my debt. The information provided to the Credit agency will only be demographic information in order to collect this debt.
- Poppy’s Therapeutic Corner, LLC has your permission to release your protected health information to your insurance company.
- In order to receive services from Poppy’s Therapeutic Corner, LLC you are agreeing to the conditions outlined above
Client or Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
**Your Credit Card will not be charged once you click submit**
Should be Empty:

Client Information

Referral Source

Emergency Contact Information

Client History

Previous Treatment

Medical History

Marital History

Legal History

Safety

Fee Agreement